Assessments Flashcards
What is a primary assessment?
ABCDE
Airway - open, clear talking
Breathing - present and adequate, SPO2, SOB, WOB, RR, Accessory muscles, sounds
Circulation - colour of skin, nails, cap refill, temp, pulse
Disability - neurological function, GCS (eyes, verbal, motor), PEARL, BGL
Exposure - injuries, bleeding, oedema, cellulitis, hypo/hyperthermia
What are ‘normal’ vital signs?
HR - 60-100bpm
BP - 120/80mmHg
SPO2 - 95-100%
Temp - 36.5-37.2
RR - 12-20 breaths/min
What is
- objective data
- subjective data
Objective data
- unbiased facts
- See, hear, feel, auscultate and measure
- objective = observe
Subjective data
- opinions or biases
- subjective = what the patient says
What is Maslow’s Hierarchy of Needs in order of importance?
- Physiological needs - airway, SOB, WOB, HR, nutrition, elimination
- Safety and Security - protection from injury, sense of security, trust in nurse/patient relationship
- Love and belonging - support systems
- Self-esteem - control, competence, positive regard, acceptance, worthiness
- Self-actualisation - hope, spiritual wellbeing, enhanced growth
What is the ‘A’ in ABC’s?
Airway
- is the airway open
- is the airway obstructed
signs and symptoms
- stridor, gasping, cyanosis
Treatment
do you need to reposition the patient
- jaw thrust to clear airway
- do they need intubation
What is the ‘B’ in ABC’s?
Breathing
- Gas exchange taking place inside the lungs
Problems - pulmonary oedema, asthma, pneumothorax
Signs and symptoms - hyper/hypoventilation, gasping, reduced 02 saturation
Treatment
- administer oxygen, ventilate, insertion of chest tube
What is the ‘C’ in ABC’s?
Circulation
- blood circulating through the body and organs being perfused
Problems
- Cardiac arrest, hemorrhage, shock, cardiac arrhythmias
Signs and symptoms
- Weak/thready pulse, reduced pulse, no pulse, pallor, obvious bleeding
Treatment
- Administer IV fluids or blood, control bleeding, CPR
What are the 4 types of wound drainage (exudate)?
Serous
- clear, watery plasma
Serousanguineous
- pale, pink, watery mixture of clear and red fluid
Sanguineous
- bright red blood
Purulent
- thick, yellowish-green, foul odour
How would you describe pallor for a skin inspection? What would be the indications and locations of pallor?
Description
- loss of colour
Indication
- lack of blood flow
- anemia
- shock
Locations
- face
- conjunctiva
- nail beds
- palms
- lips
- mucosa membranes
How would you describe erythema for a skin inspection? What would be the indications and locations of erythema?
Description
- Redness (blanchable or not)
Indication
- inflammation
- localised vasodilation
- sun exposure
- rash
- hyperthermia
location
- Skin (area of trauma or pressure)
How would you describe jaundice for a skin inspection? What would be the indication and location of jaundice?
Description
- yellow to orange colour of the skin
Indication
- liver dysfunction
Locations
- skin
- sclera (eyes)
- mucous membranes
How would you describe cyanosis for a skin inspection? What would be the indications and locations of cyanosis?
Description
- bluish or blue tinged
Indication
- hypoxia from not enough oxygen or from impaired venous return
Locations
- peripheral cyanosis - fingertips, palms and toes
- central cyanosis - lips, tongue, mouth, mucous membranes, nail beds and skin
What BGL = Hypoglycemia and how would you treat it?
BGL is lower than 4.0 mmol
Treatment
- oral intake of carbohydrates
- recheck BGL in 15 mins
- if still low, give more carbohydrates
- give glucagon tablets
ALWAYS follow hypoglycemia pathway
Explain normal lung sounds
Bronchial (Tracheal)
- high, loud, hollow tubular sounds
- heard anteriorly only over trachea and larynx
- heard on inspiration LESS than expiration
Vesicular
- Low-pitched, breezy/rushing sound
- heard anteriorly and posteriorly
- heard on inspiration MORE than expiration
Bronchovesicular
- Medium-pitched, hollow sound
- heard anteriorly and posteriorly
- heard the SAME on inspiration and expiration
Explain the following abnormal (adventitious) lung sounds
- Wheezes
- stridor
- fine crackles (rales)
- course crackles (rales)
- Pleural friction rub
Wheezes
- high pitched musical instrument with more than one type of sound quality (polyphonic), due to air moving through a narrow airway
- eg. asthma, bronchitis, chronic emphysema
Stridor
- High pitched whistling or gasping with a harsh sound quality due to disturbed airflow in the larynx or trachea
- eg. croup, epiglottitis, airway obstruction
Fine crackles (rales)
- high pitched crackling sounds
- previously deflated airways that are popping back open
- eg. pulmonary oedema, asthma, COPD
Course crackles (rales)
- low pitched wet bubbling sounds
- Inhaled air is colliding with secretions in the trachea or large bronchi
- eg. pulmonary oedema, pneumonia, depressed cough reflex
Pleural friction rub
- low pitched harsh grating sounds
- pleura is inflamed and losing its lubricant fluid
- surfaces are rubbing together during respirations
- eg. pleuritis
What is included in a neurological assessment?
GCS (3-15)
- Eye opening response
- Verbal response
- Motor response
PEARL
- Pupils Equal And Reactive to Light
Mental Status
- Person
- Place
- Time
- Situation
